Inspection on 11/10/07 for Neilston

This inspection was carried out on 11th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Neilston 30/04/09

Neilston 02/04/08

Neilston 29/06/07

Neilston 20/06/06

Neilston 17/01/06

Neilston 22/09/04

Neilston 05/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Neilston 47 Woodway Road Teignmouth Devon TQ14 8QB Lead Inspector Graham Thomas Unannounced Inspection 11th October 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Neilston Address 47 Woodway Road Teignmouth Devon TQ14 8QB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01626 774221 01626 879395 joy@neilston.info Mr John Bryant Wescott Mrs Joy Wescott Mrs Joy Wescott Care Home 22 Category(ies) of Dementia (22), Old age, not falling within any registration, with number other category (22) of places Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29th June 2007 Brief Description of the Service: Neilston is registered to provide care for a maximum of twenty-two older people who may also have dementia. The proprietors and registered providers are Mrs Joy Wescott and Mr John Wescott who live on the premises. Mrs Wescott manages the home on a day-to-day basis and Mr Westcott takes responsibility for the upkeep of the house and garden. Neilston is situated on a hill in a quiet residential area of Teignmouth, and is approximately one mile from the town centre. It is a detached house with a substantial garden. Car parking is available on the road outside. There are 18 bedrooms single rooms and two double bedrooms. All have en-suite facilities. Accommodation is situated on the ground, lower ground and first floors. There a stair lifts to the first and lower ground floors. Communal space comprises a large lounge and a separate dining room with an adjoining sun lounge, which leads to the rear garden. Written information is provided for people considering going to live at Neilston and those who are resident. A copy of the most recent CSCI inspection report is available. The Registered Provider stated that fees currently range from £288 to £400 per week. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last Key Inspection, the Registered Providers have provided an improvement plan to the Commission which was reviewed as part of this inspection. Before the inspection visit the Registered Providers were asked supply information about the home in an Annual Quality Assurance Assessment (AQAA). This information was not supplied before the inspection visit. We visited the home on 11th and 12th October 2007 and spent a total of ten and a half hours there. During the visit we looked around the home and its gardens. We spoke with six people living at the home, interviewed two staff and spoke with a visiting Community Nurse. Various records were examined including care plans, staff files and records concerning the day to day running of the home. The system for administering medicines was also inspected. What the service does well: What has improved since the last inspection? What they could do better: • Assessments and care plans need to be improved so that carers have a full picture of residents’ needs and how to meet them • Individual special dietary requirements must be met to preserve peoples’ health • Staff must be clear that abuse can happen anywhere and how to refer any abuse to agencies outside the home Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 6 • Hazardous substances and equipment must be securely stored to ensure the safety of people living at Neilston • Chair lifts must be kept in good working order • Staff must be properly checked before working in the home to ensure they are safe to work with vulnerable people • The standard of record keeping must improve to meet legal requirements • Accidents and other matters must be reported to the Commission • Arrangements for people at the end of their life need to be clarified Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual assessments do not provide sufficiently detailed information about the person, their needs, interests or preferences. EVIDENCE: The improvement plan provided by Mr & Mrs Wescott stated that assessments would be completed and regularly followed up. The files of two people who had recently moved to Neilston were examined. One person had moved to the home just over two weeks before the inspection visit. A Social Services Care plan was on the file. The home’s own assessment on the file had been completed the day before the person moved in. It was a basic “tick box” style of assessment which had no guidance for staff. Examination of the assessment and plan showed that basic details had not been completed such as information about the person’s care manager. Assessments of mental and physical health had not been completed, signed or Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 9 dated. Areas concerning the person’s religious, social and occupational needs and preferences had not been completed. Other areas contained little useful information. For example, under food and dietary needs and preferences the entry stated simply “encourage” The assessment and care planning of the second person was similarly basic. This also contained a care plan provided by the local authority. Nutritional needs and preferences only described how the person liked to take their tea. Information concerning bathing stated that the person “needs help and supervision” but did not give any detail. There was no record of the person’s hobbies or interests. Mrs. Wescott confirmed that the home has not sent letters to people recently admitted or their representatives to confirm that the home can meet their needs. Neilston does not provide intermediate care. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans continue to lack sufficient detail to provide consistent care. There is some evidence that people’s health may be placed at risk by a failure to understand or carry out the requirements of the care plans. Practices concerning the use of medicines have improved. EVIDENCE: People with whom we spoke during the visit said that staff were kind and helpful. The Registered Manager has recently introduced a new assessment and care planning system. A sample of five individual files were examined. These comprised of initial assessments, care plans and daily care plans for quick staff reference. In general the assessments and plans lacked sufficient information about individual needs and preferences. As described in the previous section of this report, some basic details were missing such as records of the person’s Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 11 hobbies and interests and their wishes at the time of their death. Elements of the plans such as risk assessments were not consistently signed and dated. In one plan some cuts had been noted on a body chart. This was not signed or dated. Some details in the daily care plans did not provide sufficient information for staff. For example, daily care plans concerning bathing contained phrases such as “needs help” without further instruction. Some files contained no detailed plan. Apparently conflicting information appeared in some plans. For example, in one plan the falls risk assessment described the risk as “low”. In the care / action plan section of the file, a note described a “high falls risk”. In the same file the local authority plan stated that the person was prone to constipation and urinary infections and that this required monitoring. The daily care plan simply stated “continent” One plan identified needs which were clearly not understood by staff or being met. In the local authority plan and the home’s own plan it was clearly stated that the person required a diet adapted to her needs as a diabetic. These plans referred to a diet low in sugar, high in fibre and with increased fluid intake. The home’s cook was aware that the person was a “mild diabetic” but stated that the person had “the same as everyone else”. On the first day of the inspection visit, the lunch time meal included a chocolate pudding with custard and the evening meal included a flan made with tinned fruit with a high sugar content. There was no charting of fluid intake and only general instructions to staff in the daily care plan. All the residents with whom we spoke said that they could see the Doctor when they needed to. Care plans contained details of general and specific health care appointments checks and treatments such as nursing and chiropody. A visiting Nurse described the home as warm, friendly and helpful and stated that staff generally complied with any recommended treatment regimes. During the inspection visit a Doctor visited the home to see a resident at the request of the Registered Manager. The home’s system for administering medicines was examined. Medication was held securely in the home’s office. A monitored dosage system was in use. The medication records of three people were inspected. These were found to be up to date and in good order. No homely remedies were in use at the time of this inspection. Controlled drugs were held with additional security. The only controlled drug in use was being administered in a patch form by the visiting Nurse. This was signed for in the controlled drugs register but with only one signature. There was a separate refrigerator for medicines requiring cool storage. Some medications that were overdue for return were found in this refrigerator. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 12 All the residents with whom we spoke felt that they were treated with dignity and respect. Staff were observed talking with residents in a supportive and helpful manner. During the inspection visit, personal care took place in private with doors closed. The wishes of residents and their representatives about arrangements for people upon their death were not consistently recorded in the care plans. The visiting Nurse expressed concerns about arrangements for those at the end of life who might have remained in the home with nursing support. In two recent incidents people coming to the end of their lives had to be removed against the wishes of the local nursing team. This appeared to have occurred because of disagreements or misunderstandings about funding arrangements. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some group activities are provided, individual religious, social and cultural needs and preferences are not sufficiently well recorded. Dietary preferences and needs are not well met. EVIDENCE: Activities recorded in the home’s activities log included Tai Chi, walks, quizzes, sing-along and ball games. During the inspection visit residents enjoyed singing and listening to the organ. Staff were seen playing table top games with residents and accompanying them for walks. Others people were seen reading the paper and watching television. Individual religious, social and cultural needs were not consistently recorded in individual plans. More able people were able to make choices regarding their daily routines such as going into Teignmouth unaccompanied and attending church with the Registered Manager. People living at Neilston confirmed that their visitors were always made welcome and offered a cup of tea. This was confirmed by one visitor with Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 14 whom we spoke during the inspection visit. The warmth of welcome was also confirmed by a visiting Nurse. Residents with whom we spoke praised the quality of the meals. The meals seen during the inspection were of a satisfactory standard. On the first day of the visit, the midday meal comprised roast chicken with vegetables, roast potatoes followed by chocolate sponge. A ham and vegetable pie was being prepared for tea to be accompanied by a tinned-fruit flan. There was no choice of menu offered at lunchtime. However, both the Registered Provider and the cook said that they knew people’s likes and dislikes and that an alternative was always available. We observed the lunch time meal during which staff were seen offering discreet help to residents. Two people said that they did not want the meal presented but no alternative was offered. A choice of menu is offered at teatime. Dietary preferences and needs were not consistently observed. The dietary needs of one person with diabetes were not being met at the time of this inspection visit. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents of Neilston and their relatives can feel confident that their concerns will be listened to and acted upon. EVIDENCE: Neilston has a written complaints procedure. This is contained in the statement of purpose and service users’ guide and was on display in the home. People with whom we spoke during the inspection felt confident that staff would listen to their concerns and act upon them. The complaints record showed one complaint regarding the temperature of a person’s room which has been addressed. The home has an adult protection policy and a copy of the local adult protection procedures. Staff have received training in the protection of vulnerable adults. In discussion, some staff were not clear about agencies outside the home to whom they might report abuse directly. One staff member asserted that abuse “could not happen here”. Another was unable to understand our questions about the issue. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Neilston provides comfortable and clean accommodation for its residents. However, There is inadequate monitoring of safety hazards, especially in the garden. His poses potential risks to people living at the home. EVIDENCE: Neilston is situated close to the seaside town of Teignmouth and all its amenities. There is ample free car parking space on the public road outside the premises and some limited parking in the home’s driveway. Internally the home has a complex layout. Individual accommodation is spread over ground and first floors and a lower ground floor. There are mezzanine levels between the floors. In addition there is a basement level which houses the laundry, food store and staff accommodation. The home is decorated in a homely style and has light and airy communal areas. These include a lounge, dining room with adjoining sun lounge which Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 17 leads to the garden. Substantial gardens are situated at the rear of the property. During the inspection visit we toured the premises including all the individual rooms. These were found to be well decorated, clean, comfortable and personalised to accommodate individual taste. People living in the home commented on the pleasant surroundings and the cleanliness of the accommodation. We noted that all areas were clean and free from offensive odours. Our tour confirmed that some rooms had recently been redecorated and fitted with new carpets. Mr Wescott is responsible for the maintenance and decoration of the premises, assisted by a maintenance worker. A generally good standard of maintenance was evident during our tour. However, it was noted that only the home’s main stair lift was working. Two others used for shorter flights of stairs were not working. During the inspection visit we suggested that the ground floor windows of bedrooms at the front of the property might benefit from restriction to improve the security of the home. This work was carried out immediately. Neilston has attractive gardens which have won local awards. People were seen sitting in the garden relaxing and reading during this visit. At the time of our visit Mr Wescott and the maintenance worker were working in the garden. A number of safety hazards were noted. During a tour of the building the cupboard used to store hazardous substances was left unlocked and unattended. At the start of our tour, Mr & Mrs Wescott’s dogs were roaming the garden on long tethers. This presented a potential trip hazard. Two garden sheds had been left open. These contained potentially hazardous materials and equipment. There was a container of strong disinfectant and a car battery on a table near the sheds. Hazards in the garden had been noted at the last key inspection and made the subject of a requirement. These hazards were removed and rectified immediately on our request and were the subject of an immediate requirement notice. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of skilled and experienced staff to meet the basic needs of people living at the home. However, recruitment practices are not sufficiently robust and place residents at potential risk EVIDENCE: Communication seen between staff and people living in the home during the inspection was friendly, caring and courteous. These observations were confirmed in conversations with a visitor and a visiting Nurse with whom we spoke. The carers on duty represented a range of skills and experience. At the time of this inspection the home was being staffed by four to five carers until early afternoon and three carers until mid-evening. In addition, the cook also performs some caring duties as does Mrs Wescott. A waking night carer and Mr and Mrs Wescott provide cover during the later evening and overnight. Mrs Wescott stated in her improvement plan that there have been ongoing difficulties in recruiting and retaining regular staff for cleaning duties. This means that carers carry out cleaning tasks in addition to their caring role. During this inspection staff were seen playing games and chatting with residents who were generally satisfied with the level of attention they received. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 19 Some staff continue to work long hours which may impede their work performance. Files of recently recruited staff were examined. These showed that checks were not sufficiently robust to protect people living at the home. For example, one staff member, a foreign national, had commenced duties two weeks prior to the inspection visit. An interview with this staff member and observation confirmed that she was working alone with residents. A criminal records check from her home country was seen on her file together with a copy of a UK criminal records check from a previous employer. Two testimonials that were over a year old were also on the file. These had not been followed up. No “POVA First” check had been conducted prior to starting work at the home. There was no record of experienced staff allocated to supervise her on each shift. Induction training booklets were seen for two staff. These were incomplete and one contained very little information. In interview staff confirmed that they had received training in health and safety topics such as moving and handling, infection control and fire safety. This was confirmed in the staff files. Other forthcoming training in dementia was confirmed. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living at Neilston continue to be placed at potential risk by a failure to address health and safety and record keeping issues EVIDENCE: Mr and Mrs Wescott have owned and managed the home for 18 years. Mrs Wescott is a nurse who was trained and qualified in the Philippines and she takes responsibility for the day-to-day running of the home. She holds the Registered Managers Award and is a qualified National Vocational Qualification training assessor. Systems to audit the quality of the service provided are being introduced. This includes surveys of people living at the home and others. A thorough audit of accidents had been conducted since the last inspection. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 21 There is minimal involvement with people’s finances, as either the person’s relative or a representative manages this. Where the proprietor makes payments to or on behalf of people, records and receipts were available for payments made. Recording systems did not meet the requirements of regulation. Shortfalls in care planning records and staffing records are identified in previous sections of this report. There was some evidence that this may have placed residents at risk. Some incidents affecting the welfare of residents had not been reported to the Commission as required by regulation. The “Annual Quality Assurance Questionnaire” sent by the Commission prior to the inspection had not been completed and returned before the inspection. Health and safety issues were inspected. As mentioned in the “Environment” section of this report, hazards in the garden were identified which have previously given rise to concern. These were the subject of an immediate requirement notice, together with the secure storage of hazardous substances in the home. There was evidence of a staff training programme in health and safety subjects including the control of infection. However, infection control practice was variable. One person was seen wearing gloves and aprons for and carried alcohol gel for hand cleansing. On discussion this member of staff was well aware of infection control issues. However, other staff were seen handling laundry without gloves or aprons and later working in the kitchen. Unlabelled skin creams were found in individual rooms. A tub of prescribed cream dated November 2005 was found in a chest of drawers on an upstairs landing. This poses the potential of confusion over skin creams and the risk of crossinfection. Mrs Wescott stated that a fire risk assessment had been conducted recently whose recommendations had been complied with. One illustration of this was fire strips which had been fitted to doors in the home. This risk assessment was not available for inspection. Fire extinguishers displayed labels showing recent checks. The fire log also showed recent testing of the alarm system and emergency lighting. Comprehensive records were available concerning faults identified and repairs carried out. There were also records of recent electrical testing. Room by room risk assessments had been carried out but there was some confusion with maintenance issues. For example, one risk assessment referred to the replacement of a “smelly carpet”. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 3 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 1 1 Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(a) Requirement All prospective residents must have a comprehensive assessment of their needs, which is recorded. This will ensure that care staff are aware of and have planned for the person’s needs prior to their admission to the home. Previous timescale of 02/09/07 not met. All residents’ care plans must set out in detail the actions that need to be taken by the staff to meet the residents’ individual health, personal and social care needs. The care plans must include a risk assessment with written guidance for the staff on how to reduce any risks identified. Previous timescales of 20/6/06 and 28/02/07 not met 02/10/07. The Registered Person must promote the health and welfare of individual service users by providing a diet which meets their needs and accords with the DS0000003759.V349340.R01.S.doc Timescale for action 01/12/07 2 OP7 15(1), 15(2)(b) and (c) 01/12/07 3 OP8 OP15 12(1)(a) 11/11/07 Neilston Version 5.2 Page 24 individual plan of care. 4 OP18 13(6) The Registered Person must ensure that all staff are trained in safeguarding adults from abuse and know how to refer such issues to agencies outside the home. Hazardous substances used within the home must be securely stored when not in use. Immediate requirement issued. All chair lifts in the home must be maintained in good working order. 31/01/08 5 OP19 13(4)(a) 11/10/07 6 OP19 23(2)(c) 01/12/07 7 OP29 19 The Registered Person must 11/10/07 ensure that recruitment practices meet the requirements of regulation. In particular, that (i) current references and criminal records checks are sought for all prospective employees and (ii) a “POVA First” check is carried out before a member of staff is employed at short notice. (iii) Records of the above are kept in the home (iv) staff employed at short notice are placed under the supervision of a named, experienced colleague and there is a written record of this. The Registered Person must ensure that records are kept in respect of each resident as specified in Schedule 3 of the Care Homes Regulations 2001. The Registered Person must ensure that the Commission for DS0000003759.V349340.R01.S.doc 8 OP37 17(1)(a) 01/12/07 9 Neilston OP38 37 01/12/07 Page 25 Version 5.2 10 OP38 23(2)(o) Social Care Inspection is notified of deaths, illnesses and other events in accordance with regulation. Garden tools, garden chemicals, maintenance equipment and building materials must be stored securely to ensure that the garden is a safe environment. Previous timescale of 02/07/07 not met Immediate requirement issued. 11/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The Registered Person should write to prospective residents following assessment confirming that the home can meet their needs. Staff would benefit from training in undertaking and recording assessments of people’s needs and plans of care. The Registered Person should consult with persons living at the home and / or their representatives about their wishes concerning arrangements at the time of their death. The Registered Person should review the home’s arrangements for caring for people in the last stages of life. This should include discussions with the local healthcare team to resolve any disagreements or misunderstandings about funding and staffing arrangements. A choice of menu should be available at all times . DS0000003759.V349340.R01.S.doc Version 5.2 Page 26 2 OP7 3 OP11 4 OP11 5 Neilston OP15 6 OP12 The Registered Person should consult with people living at the home and/or their representatives about their religious, social, cultural and recreational interests and ensure these are included in the plan of care. Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Neilston DS0000003759.V349340.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!